Provider Demographics
NPI:1972672053
Name:SANTA CRUZ, FIDEL (MD)
Entity Type:Individual
Prefix:
First Name:FIDEL
Middle Name:
Last Name:SANTA CRUZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3100 E FLORENCE AVE
Mailing Address - Street 2:SUITE #3
Mailing Address - City:HUNTINGTON PARK
Mailing Address - State:CA
Mailing Address - Zip Code:90255
Mailing Address - Country:US
Mailing Address - Phone:323-588-3125
Mailing Address - Fax:323-588-0919
Practice Address - Street 1:3100 E FLORENCE AVE
Practice Address - Street 2:SUITE #3
Practice Address - City:HUNTINGTON PARK
Practice Address - State:CA
Practice Address - Zip Code:90255
Practice Address - Country:US
Practice Address - Phone:323-588-3125
Practice Address - Fax:323-588-0919
Is Sole Proprietor?:No
Enumeration Date:2006-11-06
Last Update Date:2020-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA310662084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A310660Medicaid
CAA31066Medicare PIN
A84167Medicare UPIN